Monday, November 22, 2010

ER'body up in my shizzle

Hooray for the emergency department rotation!  It is so nice to be back on my feet again.  It's odd for me to say that, because I am actually one of the laziest people I know and will gladly camp out on my ass if I can get away with it, but I am actually happier when I have spent the day on my feet.  The emergency room at our hospital is quite busy, but also at a reasonable pace most of the time, so I've really enjoyed the experience.

Of course, as the surgical intern, I get special treatment.  Not in the sense that I get Starbucks coffee when I snap my fingers (although a super-nice medicine resident volunteered to get me a free Peppermint Mocha, yum!), but in the sense that the ER residents and attendings try to throw semi-surgical stuff my way.  For example, I spent an entire shift on only 5 patients, because 4 out of 5 of them needed complex suturing.  This probably annoyed the ER attendings, but I've decided not to worry about them because I was doing what they might otherwise consider to be busy work.  It also means that if a patient does turn out to be surgical, I am expected to write the consult and then call the surgical resident to let him or her know about it, and have them come down and see the patient.  Overall, I don't mind doing it, because it's nice to have practice writing consults while there is still someone looking over my shoulder to point out things I may have forgotten.  But it has led to a few minor conflicts where I was trapped between the surgical team (who wanted me to go ahead and do all the admission paperwork as well) and the ER attendings (who wanted me to see the patient with a cold).  I suspect this being-stuck-between-a-rock-and-a-hard-place business will not go away anytime soon.

Fortunately, the ER attending on the previous shift had already called in the facial surgeon to come by and see two of them, and he was kind enough to show me how to get around cartilage in the face and create flaps.  The issue with suturing on the head is that 1) there's a lot of bleeding, 2) skin is thinner in some parts, 3) you want a good cosmetic result but chunks of skin can be missing so it's hard to get the edges to fit together nicely.  Dr. E and I started with a 85 year old lady with dementia who fell getting out of the car, and smacked her head up pretty well.  She had lacerations to her scalp, eyebrow, nose, 4 on her arms, one on her knee and one on her ankle.  Additionally, being elderly, her skin was like paper and really difficult to fit together, since chunks were missing and the edges were abraded.  We started with the scalp, and Dr. E showed me that if you're missing tissue and you're worried about approximating the edges but creating tension and/or wrinkles, you can get your clamp under the skin and loosen up the tissue from its anchor.  This allows you to yank the skin over a bit more, and then you can snip away the zig-zag edges of the wound and create a nice clean line to sew.  We did the same thing on the nose, which is a little trickier but still doable.  Using the same technique for the eyebrow, we gave the patient a minor eyebrow lift (the patient's husband was amused), then stapled the remaining lacerations on her extremities.

A second patient proved to be even more interesting, as he had been jabbed through the ear while working at a construction site.  He had a gaping hole in the ear, which of course had very funky edges, and cartilage hanging out at odd angles.  The first interesting part was actually where you put the lidocaine for local anesthesia.  If you inject all around the hole, you'll blow up the tissue and have a hard time making the edges fit.  Instead, you can use a nerve block in and around the ear to get most of the anesthesia, and then you only need a little bit for the actual wound.

My real patient was much less bloody.
Again, Dr. E showed me how revising the edges and even enlarging the cut can allow for better approximation of the edges, so that it looks more like a natural curve in the ear with no buckles in the cartilage tissue.  The trick is to use some fine nylon suture, and make sure to check front and back of the ear for lacerations because the hole may be differently shaped from the front and the back.

Overall, the ER has been good times.  Although there is often a time pressure to either admit or discharge (ie, crap or get off the pot), I like that the thought process is still about doing your business and then moving on to the next important thing.  I have to again emphasize that I am not very good at shift work and my body always feels messed up afterwards, but I handled my overnight shift with only a few yawns, and it is oddly enjoyable to have a weekday off to study, even if the trade-off was working all weekend.  Maybe it's the quietness of the day to myself.  Maybe it's getting to sleep in late and eat breakfast with my boyfriend in his building's restaurant for once.  Or, maybe it's just knowing that I could drink leftover Halloween "Blood" Rum Punch with lunch on a Monday and nobody can say anything about it.

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